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Acute-Onset Dyspnea and Superior Vena Cava Syndrome During Dialysis
Acute-Onset Dyspnea and Superior Vena Cava Syndrome During Dialysis Sally G. Stander, MD,* Harendra Arora, MD,* Benjamin Haithcock, MD,† and Priya A. Kumar, MD*
Fig 1. The 2D TEE image showing the upper esophageal ascending aorta short-axis view.
Fig 2. The 2D TEE image showing the upper esophageal ascending aorta long-axis view.
A
tracheostomy collar. A transesophageal echocardiograph was performed as part of the diagnostic evaluation (Figs 1-4 and Videos 1-5 [supplementary videos are available online]). What is the diagnosis?
30-YEAR-OLD WOMAN with end-stage renal disease secondary to polycystic kidney disease presented to an outside hospital for acute pancreatitis. While receiving hemodialysis through a left femoral loop graft, she had acute facial swelling and respiratory distress that required control of her airway. A tracheostomy had to be emergently performed after several failed attempts at tracheal intubation. The patient was transferred to the authors’ hospital for the treatment of ongoing management of pancreatitis and respiratory distress. Upon arrival, the facial swelling had improved, and the patient was breathing spontaneously on a
From the Departments of *Anesthesiology and †Surgery, University of North Carolina, Chapel Hill, NC. Address reprint requests to Priya A. Kumar, MD, Department of Anesthesiology, N2201 University of North Carolina Hospitals, Campus Box 7010, Chapel Hill, NC 27599-7010. E-mail: pkumar@ aims.unc.edu © 2012 Elsevier Inc. All rights reserved. 1053-0770/2606-0031$36.00/0 doi:10.1053/j.jvca.2011.12.014 Key words: superior vena cava syndrome, acute-onset dyspnea, superior vena cava syndrome, dialysis
1150
Fig 3. The 2D TEE image along with color-flow Doppler showing the upper esophageal ascending aorta short-axis view. (Color version of figure is available online.)
Journal of Cardiothoracic and Vascular Anesthesia, Vol 26, No 6 (December), 2012: pp 1150-1152
ACUTE-ONSET DYSPNEA AND SVC SYNDROME
Fig 4. The 3D TEE image showing the upper esophageal ascending aorta short-axis view with the probe slightly rotated to the right. (Color version of figure is available online.)
DIAGNOSIS: MIGRATED VASCULAR STENT IN THE RIGHT PULMONARY ARTERY
The radiologists and thoracic surgeons were consulted regarding the foreign body in the pulmonary artery and decided that a percutaneous retrieval would be too risky; they were concerned about damaging the valves. A surgical approach via a midline sternotomy incision was planned. The pericardium was opened, and the right main pulmonary artery was dissected. The upper- and lower-lobe pulmonary veins on the right side also were isolated. The pulmonary artery and vein were clamped under transesophageal echocardiographic guidance, and the right main pulmonary artery was opened. After the removal of the stent (Fig 5), the pulmonary artery aortotomy was repaired, all clamps were removed, and hemostasis was achieved. The sternotomy incision was closed, and the patient was taken to the surgical intensive care unit in stable condition. The patient recovered from this procedure with resolution of her respiratory symptoms. However, she had a complicated hospital course because of her comorbid conditions and died several days later of sepsis. Apart from assessing volume status and cardiac and valvular function, the intraoperative transesophageal echocardiographic examination allowed the identification, location, and real-time visualization of the dislodged stent. It was reassuring that the stent was oriented such that there was flow maintained around it (Video 4), which may have contributed to the relative stability of the patient. The stent had migrated a considerable distance from its original placement, and any further changes in position would be important to identify. The transesophageal echocardiographic examination also confirmed that there was an adequate length of the right pulmonary artery proximal to the stent to allow for clamping. If the stent was more proximally placed either nearer to or in the main pulmonary artery, that would have required the institution of cardiopulmonary bypass. Therefore, real-time transesophageal echocardiography was helpful in determining the site for the cross-clamp and the arteriotomy. The stent clearly was visible in the right pulmonary artery with the cross-clamp placed proximal to it.
1151
Migrations of vascular stents, particularly those placed to extend arteriovenous access for dialysis, have been reported previously. The incidence of stent migration determined from a 24-month study at one vascular access center was 2% for all stents and 2.7% for covered stents.1 Numerous approaches have been taken to address the problem, ranging from the most conservative “wait-and-see” approach to percutaneous interventions and surgical removal.1-4 Although reports of percutaneous retrieval of stents in the pulmonary artery have been reported, more commonly the patients are anticoagulated and managed conservatively. A case reported by Sharma et al5 was managed with a watch-and-wait approach, and no complications were evident after 7 years. In a series of cases of stent migration and retrievals by Gabelmann,3 3 of 28 cases were migrations to the pulmonary artery. No attempts at percutaneous removal were made because the risks of cardiac valve injury were too high. Although there were no complications reported in these 3 patients, severe complications, including pulmonary infarction, have been reported, one resulting in death.6,7 Many considerations must be taken into account and a plan developed on a case-by-case basis to determine the best course of action. These include the stability and medical comorbidities of the patient, resources and experience of the providers, and the location and positioning of the stent. In the previously mentioned case, the acute onset of symptomatology with the initiation of dialysis and the de-
Fig 5. The vascular stent after removal from the right pulmonary artery. (Color version of figure is available online.)
1152
STANDER ET AL
velopment of dyspnea, facial swelling, and superior vena cava syndrome may have resulted from the dislodgement of the stent from the left femoral graft and possible migration into the right atrium, perhaps obstructing venous drainage leading to acute facial swelling. Its further course through
the main pulmonary artery with variable pulmonary flow dynamics may have resulted in further symptomatology. Fortunately, it lodged in the right pulmonary artery in an orientation such that there was minimal flow obstruction, hence the favorable outcome.
REFERENCES 1. Dashkoff N, Blessios GA, Cox MR: Migration of covered stents from hemodialysis A-V access to the pulmonary artery: Percutaneous stent retrieval and procedural trends. Catheter Cardiovasc Interv 76:595-601, 2010 2. Chiu KM, Chu SH, Chan CY: Dislodged caval stent in right pulmonary artery. Catheter Cardiovasc Interv 70:799-800, 2007 3. Gabelmann A, Krämer SC, Tomczak R, et al: Percutaneous techniques for managing maldeployed or migrated stents. J Endovasc Ther 8:291-302, 2001 4. Marcy PY, Magné N, Bruneton JN: Strecker stent migration to
the pulmonary artery: Long-term result of a “wait-and-see attitude”. Eur Radiol 11:767-770, 2001 5. Sharma AK, Sinha S, Bakran A: Migration of intra-vascular metallic stent into pulmonary artery. Nephrol Dial Transplant 17:511, 2002 6. Anand G, Lewanski CR, Cowman SA, et al: Superior vena cava stent migration into the pulmonary artery causing fatal pulmonary infarction. Cardiovasc Interv Radiol 34:S198-S201, 2011 (suppl 2) 7. Sy A: Pulmonary infarction due to vascular stent migration. South Med J 99:1003-1004, 2006
Fig 1. The 2D TEE image showing the upper esophageal ascending aorta short-axis view.
Fig 2. The 2D TEE image showing the upper esophageal ascending aorta long-axis view.
A
tracheostomy collar. A transesophageal echocardiograph was performed as part of the diagnostic evaluation (Figs 1-4 and Videos 1-5 [supplementary videos are available online]). What is the diagnosis?
30-YEAR-OLD WOMAN with end-stage renal disease secondary to polycystic kidney disease presented to an outside hospital for acute pancreatitis. While receiving hemodialysis through a left femoral loop graft, she had acute facial swelling and respiratory distress that required control of her airway. A tracheostomy had to be emergently performed after several failed attempts at tracheal intubation. The patient was transferred to the authors’ hospital for the treatment of ongoing management of pancreatitis and respiratory distress. Upon arrival, the facial swelling had improved, and the patient was breathing spontaneously on a
From the Departments of *Anesthesiology and †Surgery, University of North Carolina, Chapel Hill, NC. Address reprint requests to Priya A. Kumar, MD, Department of Anesthesiology, N2201 University of North Carolina Hospitals, Campus Box 7010, Chapel Hill, NC 27599-7010. E-mail: pkumar@ aims.unc.edu © 2012 Elsevier Inc. All rights reserved. 1053-0770/2606-0031$36.00/0 doi:10.1053/j.jvca.2011.12.014 Key words: superior vena cava syndrome, acute-onset dyspnea, superior vena cava syndrome, dialysis
1150
Fig 3. The 2D TEE image along with color-flow Doppler showing the upper esophageal ascending aorta short-axis view. (Color version of figure is available online.)
Journal of Cardiothoracic and Vascular Anesthesia, Vol 26, No 6 (December), 2012: pp 1150-1152
ACUTE-ONSET DYSPNEA AND SVC SYNDROME
Fig 4. The 3D TEE image showing the upper esophageal ascending aorta short-axis view with the probe slightly rotated to the right. (Color version of figure is available online.)
DIAGNOSIS: MIGRATED VASCULAR STENT IN THE RIGHT PULMONARY ARTERY
The radiologists and thoracic surgeons were consulted regarding the foreign body in the pulmonary artery and decided that a percutaneous retrieval would be too risky; they were concerned about damaging the valves. A surgical approach via a midline sternotomy incision was planned. The pericardium was opened, and the right main pulmonary artery was dissected. The upper- and lower-lobe pulmonary veins on the right side also were isolated. The pulmonary artery and vein were clamped under transesophageal echocardiographic guidance, and the right main pulmonary artery was opened. After the removal of the stent (Fig 5), the pulmonary artery aortotomy was repaired, all clamps were removed, and hemostasis was achieved. The sternotomy incision was closed, and the patient was taken to the surgical intensive care unit in stable condition. The patient recovered from this procedure with resolution of her respiratory symptoms. However, she had a complicated hospital course because of her comorbid conditions and died several days later of sepsis. Apart from assessing volume status and cardiac and valvular function, the intraoperative transesophageal echocardiographic examination allowed the identification, location, and real-time visualization of the dislodged stent. It was reassuring that the stent was oriented such that there was flow maintained around it (Video 4), which may have contributed to the relative stability of the patient. The stent had migrated a considerable distance from its original placement, and any further changes in position would be important to identify. The transesophageal echocardiographic examination also confirmed that there was an adequate length of the right pulmonary artery proximal to the stent to allow for clamping. If the stent was more proximally placed either nearer to or in the main pulmonary artery, that would have required the institution of cardiopulmonary bypass. Therefore, real-time transesophageal echocardiography was helpful in determining the site for the cross-clamp and the arteriotomy. The stent clearly was visible in the right pulmonary artery with the cross-clamp placed proximal to it.
1151
Migrations of vascular stents, particularly those placed to extend arteriovenous access for dialysis, have been reported previously. The incidence of stent migration determined from a 24-month study at one vascular access center was 2% for all stents and 2.7% for covered stents.1 Numerous approaches have been taken to address the problem, ranging from the most conservative “wait-and-see” approach to percutaneous interventions and surgical removal.1-4 Although reports of percutaneous retrieval of stents in the pulmonary artery have been reported, more commonly the patients are anticoagulated and managed conservatively. A case reported by Sharma et al5 was managed with a watch-and-wait approach, and no complications were evident after 7 years. In a series of cases of stent migration and retrievals by Gabelmann,3 3 of 28 cases were migrations to the pulmonary artery. No attempts at percutaneous removal were made because the risks of cardiac valve injury were too high. Although there were no complications reported in these 3 patients, severe complications, including pulmonary infarction, have been reported, one resulting in death.6,7 Many considerations must be taken into account and a plan developed on a case-by-case basis to determine the best course of action. These include the stability and medical comorbidities of the patient, resources and experience of the providers, and the location and positioning of the stent. In the previously mentioned case, the acute onset of symptomatology with the initiation of dialysis and the de-
Fig 5. The vascular stent after removal from the right pulmonary artery. (Color version of figure is available online.)
1152
STANDER ET AL
velopment of dyspnea, facial swelling, and superior vena cava syndrome may have resulted from the dislodgement of the stent from the left femoral graft and possible migration into the right atrium, perhaps obstructing venous drainage leading to acute facial swelling. Its further course through
the main pulmonary artery with variable pulmonary flow dynamics may have resulted in further symptomatology. Fortunately, it lodged in the right pulmonary artery in an orientation such that there was minimal flow obstruction, hence the favorable outcome.
REFERENCES 1. Dashkoff N, Blessios GA, Cox MR: Migration of covered stents from hemodialysis A-V access to the pulmonary artery: Percutaneous stent retrieval and procedural trends. Catheter Cardiovasc Interv 76:595-601, 2010 2. Chiu KM, Chu SH, Chan CY: Dislodged caval stent in right pulmonary artery. Catheter Cardiovasc Interv 70:799-800, 2007 3. Gabelmann A, Krämer SC, Tomczak R, et al: Percutaneous techniques for managing maldeployed or migrated stents. J Endovasc Ther 8:291-302, 2001 4. Marcy PY, Magné N, Bruneton JN: Strecker stent migration to
the pulmonary artery: Long-term result of a “wait-and-see attitude”. Eur Radiol 11:767-770, 2001 5. Sharma AK, Sinha S, Bakran A: Migration of intra-vascular metallic stent into pulmonary artery. Nephrol Dial Transplant 17:511, 2002 6. Anand G, Lewanski CR, Cowman SA, et al: Superior vena cava stent migration into the pulmonary artery causing fatal pulmonary infarction. Cardiovasc Interv Radiol 34:S198-S201, 2011 (suppl 2) 7. Sy A: Pulmonary infarction due to vascular stent migration. South Med J 99:1003-1004, 2006